The nurse is caring for an elderly client with type II diabetes who has had nausea, vomiting and diarrhea for several days and who now is disoriented and listless. Initial vital signs: B/P 72/62, pulse 146 irregular and thready, respirations 38 breaths per minute and shallow, and temperature of 97.0 F rectally. The skin is cool and clammy. The nurse recognizes that this client's symptoms are most indicative of which stage and type of shock? The:
initial stage of septic shock.
refractory stage of obstructive shock.
progressive stage of hypovolemic shock.
compensatory stage of diabetic shock.
The Correct Answer is C
A. Initial stage of septic shock
Septic shock typically presents with warm, flushed skin in the early phase due to vasodilation. This client has cold and clammy skin, which is more consistent with hypovolemic shock.
B. Refractory stage of obstructive shock
Obstructive shock (e.g., from cardiac tamponade or pulmonary embolism) would present with jugular vein distention, muffled heart sounds, or severe respiratory distress, which are not seen in this case.
C. Progressive stage of hypovolemic shock
The client has classic signs of hypovolemic shock due to fluid loss (nausea, vomiting, diarrhea). The progressive stage is indicated by hypotension, tachycardia, and end-organ dysfunction (altered mental status, cool/clammy skin).
D. Compensatory stage of diabetic shock
"Diabetic shock" is not a standard classification of shock. The compensatory stage would still have an adequate blood pressure due to SNS activation, but this patient already has profound hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.
B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.
C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.
D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.
Correct Answer is C
Explanation
A. Respiratory rate 24 and bloody drainage in the NG tube
While an increased respiratory rate and bloody drainage are concerning, they may not indicate an immediate life-threatening situation compared to the other options.
B. Client is oriented to name and place but not the date
This suggests some level of confusion or altered mental status, which is important but not necessarily an immediate threat.
C. Blood pressure 40/48 and urine output of 24 mL/hour
This indicates severe hypotension and inadequate perfusion, which are signs of ongoing shock and possibly continued internal bleeding. Immediate intervention is critical.
D. Hypo-active bowel sounds and tachycardia
Hypo-active bowel sounds and tachycardia are concerning and suggestive of shock, but they are not as immediately life-threatening as severely low blood pressure and low urine output.
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